Effective Health Care: Barriers and Potential Solutions

1. Effective Health Care: Barriers and Potential Solutions Dr. Jennifer Thake

2. Today’s talk • Symptom recognition • Interpretation of the symptom as serious • Using health services • Treatment delay • Provider-patient communication • Health system & navigation

3. Recognizing symptoms • Before we seek medical care, we need to recognize & interpret symptoms as being signs of illness • We actually have limited awareness of what is going on in our bodies • We are not very accurate in our perceptions (e.g., BP, HR, nasal vs physiological measures)

4. Recognizing symptoms Many things influence whether we “experience” symptoms (personality, situations, etc.)

5. Recognizing symptoms: Individual differences 1) Some people simply experience more symptoms 2) Differences in our ability to tolerate symptoms • E.g., uniform threshold for noticing pain (-44/-46 C); however, differences in the degree of pain we can tolerate

6. Recognizing symptoms: Individual differences 3) Some have more sensitivity to their bodily sensations (“internally focused”) • However, does not mean they are more accurate • Magnify normal bodily changes (heart rate) • Research: • “Internally focused” patients who seek medical treatment tend to have less severe illness and perceive their recovery as slower, versus those who pay less attention to their internal states

7. Internal focus Neuroticism • Marked by experience of negative emotions (especially anxiety), internally focused, and a concern with bodily processes • May exaggerate symptoms or simply be more attentive • Have found link between anxiety and increased reports of physical symptoms

8. Psychopathology Hypochondria (4-5% of population) • People who are preoccupied and worried that normal bodily symptoms are indicators of illness

9. Situational Factors When attention is directed outward rather than inward, symptoms are less likely to be noticed • playing sports vs. sitting in lecture • boring vs. exciting part of movie

10. Situational Factors Example: Medical Students’ Disease • Studying symptoms leads to greater focus on one’s own symptoms (e.g., of fatigue) • Interpreted as indicative if disease. • > 2/3 come to believe, incorrectly, that they have one of the diseases

11. Experience of Stress Greater reports of symptoms when stressed. Why? • We may believe we are more vulnerable to illness, and so we attend to our bodies more • May interpret stress symptoms as illness symptoms • May experience real symptoms, but the symptom is exaggerated (flu + stress = mega flu) • May flair up chronic conditions (e.g., ulcers)

12. Mood Influences our self-appraised health • People in a negative mood: • report more symptoms, • more pessimistic about efforts to relieve symptoms, • believe more vulnerable to future illness • Related to “states of mind”: may recall more illness-related memories

13. Mood • Influences our self-appraised health • People in a positive mood: • rate themselves as more healthy • report fewer illness-related memories, • report fewer symptoms • even if have a diagnosed illness!

14. Gender • In pain research – women report feeling discomfort at lower stimulus intensities than men and request sooner that a painful stimulus be terminated • Evidence for several factors in gender differences in symptom perception including gender roles

15. Culture • Reliable cultural differences in how quickly and what kind of symptoms are recognized • Reasons underlying these differences are not totally understood • May result from cultural norms for reinforcing stoical vs. distressed behaviours when in pain

16. Culture • Cultural differences have been seen in what symptoms people tolerate (Sanders et al., 1982) • Research: Compared the behavioural and emotional functioning of low-back pain sufferers from six different countries. • Americans reported the greatest overall impairment, Italians and New Zealanders reported the second largest impairments, followed by Japanese, Columbian, and Mexican pain patients.

17. Culture • Menopause symptoms among Canadian, American and Japanese women • North American women more likely to report multiple symptoms • Why? • “menopause” has a different meaning in Japanese; • dietary differences (soy & certain teas reduce hot flashes); • Japanese women healthier (fewer chronic diseases)

18. Interpreting as SERIOUS

19. Interpreting as SERIOUS Symptoms are typically interpreted as serious & activate treatment seeking if: • Affect highly valued parts of the body or organs (eyes/face vs. trunk) • Limit mobility & daily activities • Cause pain

20. Accurate Illness Schema • For certain life-threatening illnesses, recognizing that symptoms may reflect a serious health problem is critical for survival • Requires an accurate “illness schema” • Ideas and expectations about illness • Range from being inaccurate/unformed to extensive/technical/complete

21. Illness Schemas • Conceptions include: • Illness identity (name & symptoms); • Cause (how one gets it); • Timeline (how long it takes to appear/last); • Consequences/seriousness

22. Illness Schemas • Developing accurate schemas through public education campaigns • Heart and Stroke Foundation • “Recognize the signs of stroke when you see them” (30 sec commercial) • Results: ER visits for strokes increased during the campaign, suggestion an increased awareness of warning signs ** stroke awareness still low among women

23. What is the first thing you do when you experience a new symptom but you are not really sure what do to about it? Do you go to the doctor right away?

24. Lay referral network • “an informal network of family and friends who offer their own interpretation of symptoms” • Typically before medical treatment (70%) • Provides help in a variety of ways. How?

25. Lay referral network • Offer an interpretation of the symptom • Recommend remedies • Provide advice about seeking treatment • Recommend we consult another lay person

26. Lay referral network • Beneficial? • One longitudinal study suggests that the answer is “yes” • Found that seekers of information about cancer from friends and family were more likely to exercise and eat more daily fruits and vegetables one year later compared to non seekers • Looking for advice may reinforce a commitment to engage in healthy lifestyle

27. The Internet

28. The Internet Look for information about: • specific diseases, • lifestyle (diet, exercise), • specific symptoms, • home remedies, • drugs and medications, etc.

29. The Internet • 77% of women and 66% of men seek health or medical information online • 96% of doctors say may affect health care positively • Many doctors themselves turn to the internet for the most up-to-date information on illnesses, treatments, and healthy lifestyle tips

30. “Cyberchondria” • Excessive internet use to gain health info • Escalation: search for a common symptom (headache) changed to a search for a more serious health issue (brain tumour) • Many do not check the accuracy

31. “Cyberchondria” • For some people, seeking information can actually relieve their concern, which then reinforces conducting internet searches • For others, seeking symptom information can increase anxiety and can spiral into excessive searching

33. Treatment Seeking • Treatment seeking is not straightforward • Not everyone who is sick goes to the doctor • Not all people who go to the doctor are sick • Various factors for why someone is motivated to seek treatment • E.g., 2 people with the same symptoms do not always react the same way

34. Age • Very young and elderly use health care most frequently • Young children • develop a number of infectious childhood diseases as they are acquiring the immunities, so require frequent care from a physician • more likely to experience injuries

35. Age • Late adulthood • people begin to develop chronic conditions and diseases – increases as people age • However, even after controlling for chronic health conditions and other factors, with advancing age, CAN seniors make more physician consultations

36. Culture • Influences the types of health services used • Minorities (vs. Caucasians): • less likely to visit a specialist (may be due to the way symptoms are presented, expressed, disclosed) • less cancer screening (mammogram, pap, prostate)

37. Personality Neuroticism • Research: examined the association between neuroticism and having one’s blood pressure checked: • Low N group: did not go to doctor in 2 years • Moderate N: went but no BP checked • High N group: went & BP checked

38. “Misusing” Health Services • Complaints that are psychological rather than medical (2/3rd of physicians time) • Psychological complaints – especiallyanxiety and depression • Why visit the doctor instead of mental health professional?

39. Misusing Health Services • Distress causes a number of physical symptoms, which can be mistaken for medical problem (e.g., panic or heart attack?) • May be only available option (lack of extended health coverage) • More legitimate to have a physical complaint than a psychological complaint (gender and cultural significance)

40. Misusing Health Services • In Chinese culture, expressing emotional distress as a physical symptom is seen as more culturally acceptable because mental health symptoms carry much stigma

41. Secondary Gains • Ability to rest, • To be freed from unpleasant tasks, • To be cared for by others, and • To take time off from work ** all reinforcing

42. Malingering • “sick” is an acceptable excuse for missing work; but wasting physician’s time

43. Treatment Delay • Delay has several time periods: • time it takes someone to recognize a symptom (appraisal delay), • time it takes to recognize that the symptom implies illness and requires treatment (illness delay), • time between actually deciding to seek treatment and actually doing so (behavioural delay), • time between making an appointment and actually seeing a physician (medical delay)

44. Why Delay Treatment?

45. Provider Delay • When an appropriate test/treatment is not undertaken until it has become warranted • Rule out more common causes before proceeding to more invasive tests • More likely when a patient deviates from the profile of an avg. person with a given disease • e.g., breast cancer most common among women age 50, so a woman 25 years with a lump may be sent home vs. given a biopsy

47. Health Service Usage:Pharmacists • Often the first health professional that people consult when they have a health problem • Usually recommend an over-the-counter solution and to go to their family physician if persists

48. Health Service Usage: Visits to physicians • Most don’t avoid going to the doctor • AvgCAN doc does 3,000 consultations per year, compared with 1600 in the US • Reflects an average of 5.5 visits to doctors

49. Getting the Appointment • ON has one of the lowest physician-to-patient ratios and among the fewest family physicians available • < 10% accepting new patients • ¼ cannot get in to see a doctor on the same day when they are sick or need medical attention • >1/3 report having to wait 6+ days • Many believe the wait-time is unacceptable, affected them negatively, and experience pain, worry/anxiety/stress

50. “Strange” Providers • Many have no regular family physician (15.2%) • Creates a reliance on walk-in clinics and emergency rooms for primary care • Different provider each time • Very long, same day wait-times • Has consequences for patients, esp. if you want specialized care